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Controlling the cost of Medicaid private duty nursing services : final report to the Joint Legislative Program Evaluation Oversight Committee

Private Duty Nursing Report No. 2008- 12- 05
Page 9 of 22
• Other states require that recipients need a certain number of
skilled nursing hours. The private duty nursing policy in North
Carolina does not define continuous skilled nursing. In some states,
recipients must need at least two hours of skilled nursing care at a
time to be eligible for private duty nursing; in other states,
recipients must need at least eight hours a day of skilled nursing
care. Washington’s policy states nursing home care should be
considered for clients that need more than 16 hours a day of skilled
nursing care.
• Other states limit how the service is reimbursed. North Carolina
pays a single rate for private duty nursing services and does not
limit how much it will reimburse for the service. In contrast,
Massachusetts, Nebraska, and Tennessee will not pay more for
private duty nursing services than they would pay for institutional
care. In New York, only licensed practical nurses provide private
duty nursing services, unless recipients can demonstrate a registered
nurse needs to provide the service. Some states offer different
levels of private duty nursing. Minnesota has different
reimbursement rates for " regular" private duty nursing for non-ventilator-
dependent and non- intensive recipients and " complex”
private duty nursing for ventilator- dependent and intensive
recipients. In Ohio, recipients who are no longer making significant
improvements in their medical conditions can receive “ on- going
maintenance” private duty nursing services indefinitely, but
recipients can only receive “ post- hospital” private duty nursing for
up to 56 hours per week for up to 60 days after discharge.
North Carolina is the only southern state without any limits on private
duty nursing since Tennessee restructured its private duty nursing
benefit. Tennessee, which offers private duty nursing under the 1115
Demonstration TennCare II, recently modified its private duty nursing
benefit. Similar to North Carolina, Tennessee did not place any limits on its
private duty nursing service for adults. Tennessee attempted to eliminate
the service completely in 2005 but instead was able to achieve budget cuts
through changes in its pharmacy program. However, after seeing the cost
of private duty nursing services continue to grow over the past three years,
Tennessee decided to restructure its private duty nursing benefit. CMS
advised Tennessee to use limits that resemble the benefit structures used by
other states.
In May 2008, Tennessee proposed the limits discussed below to its private
duty nursing benefit for adults. CMS approved Tennessee’s request, and
the new limits went into effect in September 2008. Private duty nursing
services are now covered when medically necessary for two groups of
adults: those who are ventilator dependent at least 12 hours of the day
and those who have a functioning tracheostomy and require a significant
amount of other specified nursing services.
Tennessee’s definition of medical necessity requires that a service must be
the least costly alternative course of treatment adequate for the medical
condition. Thus, private duty nursing care will only be approved in an
amount up to the cost of nursing home care if a nursing home is available
and able to treat a recipient at a cost less than the cost of 24/ 7 private

Private Duty Nursing Report No. 2008- 12- 05
Page 9 of 22
• Other states require that recipients need a certain number of
skilled nursing hours. The private duty nursing policy in North
Carolina does not define continuous skilled nursing. In some states,
recipients must need at least two hours of skilled nursing care at a
time to be eligible for private duty nursing; in other states,
recipients must need at least eight hours a day of skilled nursing
care. Washington’s policy states nursing home care should be
considered for clients that need more than 16 hours a day of skilled
nursing care.
• Other states limit how the service is reimbursed. North Carolina
pays a single rate for private duty nursing services and does not
limit how much it will reimburse for the service. In contrast,
Massachusetts, Nebraska, and Tennessee will not pay more for
private duty nursing services than they would pay for institutional
care. In New York, only licensed practical nurses provide private
duty nursing services, unless recipients can demonstrate a registered
nurse needs to provide the service. Some states offer different
levels of private duty nursing. Minnesota has different
reimbursement rates for " regular" private duty nursing for non-ventilator-
dependent and non- intensive recipients and " complex”
private duty nursing for ventilator- dependent and intensive
recipients. In Ohio, recipients who are no longer making significant
improvements in their medical conditions can receive “ on- going
maintenance” private duty nursing services indefinitely, but
recipients can only receive “ post- hospital” private duty nursing for
up to 56 hours per week for up to 60 days after discharge.
North Carolina is the only southern state without any limits on private
duty nursing since Tennessee restructured its private duty nursing
benefit. Tennessee, which offers private duty nursing under the 1115
Demonstration TennCare II, recently modified its private duty nursing
benefit. Similar to North Carolina, Tennessee did not place any limits on its
private duty nursing service for adults. Tennessee attempted to eliminate
the service completely in 2005 but instead was able to achieve budget cuts
through changes in its pharmacy program. However, after seeing the cost
of private duty nursing services continue to grow over the past three years,
Tennessee decided to restructure its private duty nursing benefit. CMS
advised Tennessee to use limits that resemble the benefit structures used by
other states.
In May 2008, Tennessee proposed the limits discussed below to its private
duty nursing benefit for adults. CMS approved Tennessee’s request, and
the new limits went into effect in September 2008. Private duty nursing
services are now covered when medically necessary for two groups of
adults: those who are ventilator dependent at least 12 hours of the day
and those who have a functioning tracheostomy and require a significant
amount of other specified nursing services.
Tennessee’s definition of medical necessity requires that a service must be
the least costly alternative course of treatment adequate for the medical
condition. Thus, private duty nursing care will only be approved in an
amount up to the cost of nursing home care if a nursing home is available
and able to treat a recipient at a cost less than the cost of 24/ 7 private